[104-10222-10042.pdf — page 176]
# DECLARATION OF APPOINTEEThis form is to be completed before entrance on duty. Question 3 is to be answered in all cases, otherwise answer only those questions which require an answer different from that given to the corresponding questions on your application form. If no answers are different, write "NONE" in Item 10, below. Any false statement in this declaration will be grounds for cancellation of application or dismissal after appointment. Impersonation is a criminal offense and will be prosecuted accordingly.1. PRICENT ADDRESS (afreet and number, city and Sinte)1401 16th St. N.W. Washington D.C.2 (A) DATE OF BIRTH (B) PLACE OF BIRTH (cily of town and Stels of country)1/12/29 Dayton O. USA3. (A) IN CASE OF EMERGENCY PLEASE NOTIFY (2) PELATIONSHIP (C) STREET AND NUMBER, CITY AND STATE (D) TELEPHONE NO.Samuel D. Zehrung Father San Dee Gardens. RR11 WA 58314. DOES THE UNITED STATES GOVERNMENT EMPLOY, IN A CIVILIAN CAPACITY, ANY RELATIVE OF YOURS (EITHER BY BLOOD OR MARRIAGE) WITH WHOM YOU LIVE OR HAVE LIVED WITHIN THE PAST 24 MONTHS YES NOIf so, for each such relative fill in the blanks below. It additional space is necessary, complete under Item 10.| NAME | POST OFFICE ADDRESS (Give street number, if any) | (1) POSITION (2) TEMPORARY OR NOT | (2) DEPARTMENT OR AGENCY IN WHICH EMPLOYED | RELATION. SHIP | MAR. RIED | SINGLE (Check one) || ---- | ------------------------------------------------ | --------------------------------- | ------------------------------------------ | -------------- | --------- | ------------------ ||      |                                                  |                                   |                                            |                |           |                    ||      |                                                  |                                   |                                            |                |           |                    ||      |                                                  |                                   |                                            |                |           |                    ||      |                                                  |                                   |                                            |                |           |                    ||      |                                                  |                                   |                                            |                |           |                    ||      |                                                  |                                   |                                            |                |           |                    ||      |                                                  |                                   |                                            |                |           |                    ||      |                                                  |                                   |                                            |                |           |                    |INDICATE "YES" OR "NO" ANSWER BY PLACING "X" IN PROPER COLUMN 10. SPACE FOR DETAILED ANSWERS TO OTHER QUESTIONS|                                                                                                                                                                                                                                                                                                                                    | YES | NO  | ΤΤΕΙΑ | WPITE IN LIFT COLUMN NUMBERS OF ITEMS TO WHICH DETAILED ANSWERS APPLY || ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | --- | --- | ----- | --------------------------------------------------------------------- || 5. ARE YOU A CITIZEN OF OR DO YOU OWE ALLEGIANCK TO THE UNITED STATE                                                                                                                                                                                                                                                               | X   |     |       |                                                                       || 6. ARE YOU AN OFFICIAL, OR EMPLOYEE OF ANY STATE, TERRITORY, COUNTY, GR MUNICIPALITY!                                                                                                                                                                                                                                              |     | X   |       |                                                                       || *Il your answer is "Yes", give details in Item 10.*                                                                                                                                                                                                                                                                                |     |     |       |                                                                       || 7. 1. DO YOU AFCEIVE ANY ANHUITY FROM THE UNITED STATES UR DISTRICT COP COLUMBIA CYFPAINT UNDER AMY PER ACT OR ANY PENGIM CHIPPYNALAL                                                                                                                                                                                              |     | X   |       |                                                                       || *If you answer is" You", divn in Item 10 reason for robicama, that in, age, optional disability, or by reason of voluntary nenuntery eparation after 3, cart acteu rotirement pay, and under what retirement act, and reling. sf retued from muitaly or navel service.*                                                            |     |     |       |                                                                       || 8. HAVE YOU VIR DIEN H CHARGED OM RDRED TO REGN, FOR MISC04O OM UNSATISFACTORY SERVICE FROM ANY FOLITION.....                                                                                                                                                                                                                      |     | X   |       |                                                                       || *If your answer is "Yes", give in Itam 10 the name and address of amployer, date, and reason in each case.*                                                                                                                                                                                                                        |     |     |       |                                                                       || 9. SHOF YOUR 16TH BIRTHDAY, HAVE YOU VIR DIEN ARGESICO 14DICTER SUMMONED INTO CASA DEFENDANT IN A CHR CONりたい FINED ORIMP CRILICDONTORATION GU HAL FVER BEEN OROPPED TO LOSIT HAIL OR CA LATERAL FOR THE امر ۱۲ وارد OFANT LAN PERICULATION CRGRONALDING MITRAFIC VIOLATIONS FOR WINCHATIRE OR FORFEITUPE OF BURLLAS WAS IMPOSE OST |     | X   |       |                                                                       || *If your answer is "Yes". list all such cases under Itam 10. tina in each cate (1) Tho data, (3) the nature of the offence or violation; (3) the name and loxaton of the court. (4) it.n penalty imposed, if ans, or other disposition of the cacO*                                                                                |     |     |       |                                                                       |It appointed your fingerprints will be takenINSTRUCTIONS TO APPOINTING OFFICERThe appwooting officer before whom the foregoing certificate in riade shالص determine the own fution that the appointment would the ince with the Civil Servue Act, appeable Civil Service Kuien an itexulans and mits of Craigress pertaining to appontinent,Thue form should be the bed for holding of office pension, etablity in come netion with any recond recent dinhare of treat, and my tre the following.luantity of appointee The appetee's signattur nd sadawing are to be competed with the appl catun for other pertume. The ١٠٠٠e عاد nay be hrabred at the inedical arts are The مراوه questumed on his personal history for greatest 4.1... Previous sicurais.(2) if drimite age limite have been catchhsel for th seterrard that aplicant not outside the due range frUntil sus deterinthan to made, the apporter nut to do...(1)Citisaishin-The appointing offer in responsible for cheerving the Citzensimp proof (1) the Civil Service Nuland (4) spre piation o For C1 Claudavet for both purpleptable proud of citiveselip status in the womans of collte. In doubtle Paulanent should not bed and clearance has been se ural Gom tre cert.lyng oltre of the Civil Service Comnia.(4) Momhore of Fach Section 9 of the Civil Servis Ar provides thet wherever Cure are already two more members of a fa servir Master دارو or permanent and the petitive arovice, es wher sin eligible for predattonal or permaina the competitive serいご 1.14 ranne carth! to vetera perfrience are not subjent to thosement. The taunders prova ply to teraserary contacts, corred to ης rate otice of the Civil Service Coomva for dec.noa,16-26100-1